Event Notification Report for January 18, 2024

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
01/17/2024 - 01/18/2024

Part 21
Event Number: 56899
Rep Org: Paragon Energy Solutions
Licensee: Paragon Energy Solutions
Region: 3
City: Fort Worth   State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Richard Knott
HQ OPS Officer: Natalie Starfish
Notification Date: 12/19/2023
Notification Time: 17:34 [ET]
Event Date: 12/18/2023
Event Time: 00:00 [CST]
Last Update Date: 01/17/2024
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Taylor, Nick (R4DO)
Edwards, Rhex (R3DO)
Part 21/50.55 Reactors, - (EMAIL)
Event Text
EN Revision Imported Date: 1/18/2024

EN Revision Text: INITIAL PART 21 REPORT - DEFICIENT FUEL INJECTORS

The following is a synopsis of information was provided by the licensee via phone and email:

Pursuant to 10 CFR 21.21(d)(3)(i), Paragon provided initial notification of a defect associated with the auxiliary feedwater pump diesel engine fuel injectors supplied to Constellation. The injectors were provided to Paragon for refurbishment. Constellation provided Paragon with root cause report # 4703982 on November 12, 2023. The associated failure analysis report documented potential defects with some fuel injectors supplied to Braidwood. These reported deficiencies allowed excessive fuel oil leakage which resulted in diesel lubricating oil system contamination above specified limits. Paragon concluded their evaluation on December 18, 2023, which determined that this condition, if left uncorrected, could contribute to a substantial safety hazard and is reportable in accordance with 10 CFR Part 21.

The extent of condition is limited to the Constellation Braidwood and Byron plants.

Paragon has entered this condition in their corrective action program. Affected injectors at Braidwood have been removed from service and returned to Paragon. Paragon is coordinating with Byron on recommended actions and will follow up with a final notification on or before 1/17/2024.

* * * UPDATE ON 1/17/24 AT 1626 EST FROM RICHARD KNOTT TO ADAM KOZIOL * * *

Paragon Energy Solutions submitted a final report for this event.

Notified R3DO (Orlikowski), R4DO (Josey), and Part 21 (email).


Part 21
Event Number: 56913
Rep Org: Engine Systems, Inc.
Licensee: Engine Systems, Inc.
Region: 1
City: Rocky Mountain   State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Dan Roberts
HQ OPS Officer: Ossy Font
Notification Date: 01/04/2024
Notification Time: 16:00 [ET]
Event Date: 11/27/2023
Event Time: 00:00 [EST]
Last Update Date: 01/17/2024
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
Event Text
EN Revision Imported Date: 1/18/2024

EN Revision Text: PART 21 - EMD CYLINDER LINER WITH BORE DEFICIENCY

The following is a summary of the information provided by Engine Systems, Inc. (ESI) via fax:

An edge or lip in the bore of an EMD (Brand name: Electro-Motive Diesel) cylinder liner prevented successful installation of the corresponding power assembly on an emergency diesel generator set. The lip is located axially at the bottom of the inlet ports and is present around the circumference of the bore. The EMD model 645E4 is a 2-stroke engine with air inlet ports in the wall of the cylinder liner. As the piston travels below the inlet ports, air box pressure scavenges and replenishes air to the power assembly.

Installation of the power assembly requires lowering the piston through the liner in order to secure the connecting rod to the crankshaft. During this process the piston could not be lowered below the inlet ports due to the piston rings catching on the lip. The power assembly was not installed and therefore there was no safety hazard; however, if the defect had gone undetected there was the potential to damage engine components and possibly reduce load carrying capacity of the engine.

The extent of the condition is this single cylinder liner, P/N 9318833, S/N 20M0938 used in the power assembly at Tennessee Valley Authority (TVA) - Sequoyah Nuclear Plant, Serial Number: 23H1306.

Corrective Actions:
For TVA-Sequoyah:
No action required; the power assembly has been returned to ESI.
For ESI:
To prevent reoccurrence, ESI has revised the dedication package to include verification that bore machining is continuous along the entire length and no edges or lips are present. The revision was implemented on December 6, 2023.

* * * UPDATE ON 1/17/24 AT 1515 EST FROM DAN ROBERTS TO ADAM KOZIOL * * *

Engine Systems, Inc. sent a revision to change the date of defect identification to November 27, 2023.

Notified R2DO (Miller), Part 21 Group (email)


!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 56915
Facility: Davis Besse
Region: 3     State: OH
Unit: [1] [] []
RX Type: [1] B&W-R-LP
NRC Notified By: Ben Skilliter
HQ OPS Officer: Ernest West
Notification Date: 01/05/2024
Notification Time: 18:18 [ET]
Event Date: 01/05/2024
Event Time: 10:40 [EST]
Last Update Date: 01/17/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(C) - Pot Uncntrl Rad Rel
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Stoedter, Karla (R3DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
Event Text
EN Revision Imported Date: 1/18/2024

EN Revision Text: EMERGENCY VENTILATION SYSTEMS INOPERABLE

The following information was provided by the licensee via phone and email:

"At approximately 1111 EST on 01/05/2024, a mechanical penetration room door was discovered unlatched. Based on security badge history, the door was last opened at 1040 EST. The unlatched door resulted in both trains of the station emergency ventilation system being inoperable due to being unable to maintain the shield building negative pressure area. With both trains simultaneously inoperable, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). The door was closed and verified latched upon discovery to restore the systems to an operable status.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

* * * RETRACTION ON 1/17/24 AT 1400 EST FROM CHRIS HOTZ TO ADAM KOZIOL * * *

"The station emergency ventilation system (EVS) was tested with the mechanical penetration room door unlatched. The test results showed that the station EVS attained the required negative pressure in the shield building within the time required by the Technical Specifications. Therefore, the station EVS remained operable with the door unlatched, and this issue did not prevent the system from fulfilling its safety function to control the release of radioactive material and mitigate the consequences of an accident.

"The NRC Resident Inspector has been notified."

Notified R3DO (Orlikowski)


Part 21
Event Number: 56919
Rep Org: V. C. Summer
Licensee: V. C. Summer
Region: 2
City: Jenkinsville   State: SC
County: Fairfield
License #:
Agreement: Y
Docket:
NRC Notified By: Justin Bouknight
HQ OPS Officer: Thomas Herrity
Notification Date: 01/10/2024
Notification Time: 08:18 [ET]
Event Date: 11/12/2021
Event Time: 00:00 [EST]
Last Update Date: 01/17/2024
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
Event Text
EN Revision Imported Date: 1/18/2024

EN Revision Text: PART 21 - EATON-CUTLER HAMMER RELAY ON EMERGENCY DIESEL FAILED

The following information was provided by the licensee via email and phone call:

"On January 9, 2024, VC Summer Nuclear Station (VCSNS) determined a manufacturing defect affecting a control power circuit monitor (CP1) relay on its 'B' emergency diesel generator (EDG) was reportable under Part 21.

"On November 12, 2021, the 'B' EDG was rendered inoperable when its CP1 relay de-energized due to mechanical binding of the magnet carrier assembly. The binding was caused by a manufacturing defect that allowed heat-induced shrinkage to reduce the clearance between the magnet carrier and adjacent coil housing and base, preventing it from moving freely. VCSNS replaced the affected relay and restored operability of its 'B' EDG.

"Manufacturer/Model: Eaton-Cutler Hammer D26MRD30A1

"A written notification in accordance with 10 CFR 21.21(d)(3)(ii) will be provided within 30 days. The NRC Senior Resident Inspector has been notified."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

The plant has notified the manufacturer. It is not known if any other plants are affected by this defect.


Part 21
Event Number: 56920
Rep Org: V. C. Summer
Licensee: V. C. Summer
Region: 2
City: Jenkinsville   State: SC
County: Fairfield
License #:
Agreement: Y
Docket:
NRC Notified By: Justin Bouknight
HQ OPS Officer: Thomas Herrity
Notification Date: 01/10/2024
Notification Time: 08:18 [ET]
Event Date: 05/05/2021
Event Time: 00:00 [EST]
Last Update Date: 01/17/2024
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
Event Text
EN Revision Imported Date: 1/18/2024

EN Revision Text: PART 21 - GOULD FIELD FLASH RELAY ON EMERGENCY DIESEL FAILED

The following information was provided by the licensee via email and phone call:

"On January 9, 2024, VC Summer Nuclear Station (VCSNS) determined a manufacturing defect affecting a field flash contactor (K2) relay on its 'B' emergency diesel generator (EDG) was reportable under Part 21.

"During testing on May 5, 2021, the 'B' EDG was rendered inoperable when its K2 relay coil switch exhibited intermittent binding due to insufficient clearances of the switch actuator from the protective case and plastic switch molding. The inadequate clearances resulted in accelerated loss of graphite lubrication at these locations, which led to mechanical binding. VCSNS replaced the affected relay and restored operability of its 'B' EDG.

"Manufacturer/Model: Gould F10NOCLD1 DC coil switch

"A written notification in accordance with 10 CFR 21.21(d)(3)(ii) will be provided within 30 days. The NRC Senior Resident Inspector has been notified."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

The licensee did not notify the intellectual property owner because the manufacturer is no longer operating or in business. They are not aware of other plants that utilize this coil switch.


Agreement State
Event Number: 56921
Rep Org: WA Office of Radiation Protection
Licensee: Environmental Management & Controls
Region: 4
City: Richland   State: WA
County:
License #: B400
Agreement: Y
Docket:
NRC Notified By: Kristen Schwab
HQ OPS Officer: Adam Koziol
Notification Date: 01/10/2024
Notification Time: 13:13 [ET]
Event Date: 12/20/2023
Event Time: 00:00 [PST]
Last Update Date: 01/10/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Gaddy, Vincent (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - IMPROPER SHIPMENT HANDLING

The following is a summary of information provided by the Washington State Department of Health via email:

A shipment from Environmental Management and Controls, Inc. (EMC) to a commercial low-level radioactive waste (LLRW) disposal site near Richland, Washington, was identified as violating Department of Transportation regulations, Washington administrative code, and the LLRW disposal site license. Specific violations were (1) improper transportation vehicle utilized for a shipment with surface radiation greater than 200 mrem/hr, (2) two containers arrived with higher than manifested surface radiation levels, and (3) one container arrived with lower than manifested radiation levels.

The Washington Department of Health issued a notice of violation to the licensee which detailed required remediation including root cause analysis, corrective action plan, and a quality assurance plan in a written response. The licensee use of the LLRW disposal site was also suspended pending a passing inspection by the state of Washington. This incident was not a contamination event and is under investigation.

Washington Incident Number: WMS-DOT-23-07


Agreement State
Event Number: 56922
Rep Org: Texas Dept of State Health Services
Licensee: INEOS USA LLC
Region: 4
City: Alvin   State: TX
County:
License #: L 01422
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Ian Howard
Notification Date: 01/11/2024
Notification Time: 13:32 [ET]
Event Date: 01/11/2024
Event Time: 00:00 [CST]
Last Update Date: 01/11/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Gaddy, Vincent (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - SOURCE STUCK IN UNSHIELDED POSITION

The following information was provided by the Texas Department of State Health Services (the Department) via phone and email:

"On January 11, 2024, the licensee's service company reported to the Department that when the licensee's radiation safety officer was verifying a lock-out on an Ohmart SHLM-BR-2 fixed gauge, containing a 1,000 millicurie cesium-137 source, he found that the source had separated from the insertion rod and therefore could not be returned to the fully shielded position. The gauge operates by rod insertion of the source into a housing that is inside the reactor unit. The licensee has contacted the manufacturer to get the gauge repaired. There have been no exposures as a result of this event, and none are expected due to the location of the gauge. The intended work on the unit has been postponed until the gauge is repaired and the source can be returned to the fully shielded position. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident #: 10079
Texas NMED # TX240002


Non-Power Reactor
Event Number: 56927
Facility: Univ Of New Mexico (NEWM)
RX Type: 0.005 Kw Agn-201m #112
Comments:
Region: 0
City: Albuquerque   State: NM
County: Bernalillo
License #: R-102
Agreement: Y
Docket: 05000252
NRC Notified By: Rowdy Davis
HQ OPS Officer: Thomas Herrity
Notification Date: 01/17/2024
Notification Time: 19:20 [ET]
Event Date: 01/17/2024
Event Time: 16:16 [MST]
Last Update Date: 01/17/2024
Emergency Class: Non Emergency
10 CFR Section:
Non-Power Reactor Event
Person (Organization):
Edward Halvensten (DANU)
Linh Tran (DANU)
Andrew Waugh (DANU)
Event Text
NON-POWER REACTOR - ADMINISTRATIVE TECH SPEC VIOLATION

The following is a synopsis of information provided by the licensee via email and phone call:

On January 17th, at 1616 MST, the Reactor Supervisor violated Technical Specification (TS) 6.1.12.a. During an NRC exam, a trainee was operating the reactor under the supervision of the reactor supervisor. The doorbell rang, and the supervisor requested that the reactor be scrammed and the console power be turned off, which was accomplished. The supervisor then stepped out of the reactor room, but the key remained in the console, thus the reactor was unsecured. TS 6.1.12.a requires one reactor operator or reactor supervisor to be in the room when the reactor is not secured.